State of Maryland

STATE OF MARYLAND DEPARTMENT OF HEALTH AND MENTAL HYGIENE

Condition of Human Service Agreement Statement - DHMH 433

The following conditions are understood and accepted by the vendor organization certified below as conditions binding upon the vendor organization upon the receipt of human service agreement funds from the Department of Health and Mental Hygiene (DHMH):

1. All funds received by the vendor in connection with this award will be utilized for the purpose of the approved project as described in the Human Service Contract Proposal. All expenditures not in accordance with the human service agreement award or its modifications are the responsibility of the vendor. The vendor and its independent contractors will maintain accounting records, which are adequate to provide accountability for the use of DHMH human service funds, and maintain a written cost allocation plan, where applicable.

2. The vendor will complete reports and statements concerning the projects in the manner and form prescribed by the Department of Health and Mental Hygiene. Failure to submit any report when due may result in suspension of funding until the report is received. Failure to submit the Annual Report form DHMH 440 within 60 days after the end of agreement period may result in delay, suspension, and possible cancellation, of funding.

3. The vendor and its independent contractors will make available its project records for inspection and audit within a reasonable time, upon request by the Department of Health and Mental Hygiene. In addition, the vendor must comply with all information and data request from DHMH or its representatives.

4. The vendor agrees to comply with the “Standards for Audit of Human Services Sub- Vendors” issued by the DHMH Audit Division.

5. The vendor agrees, within 60 days after the end of the agreement period or fiscal year, whichever is earlier, to complete and electronically submit the Schedule of Sub Vendors to the DHMH Audit Division, at: [email protected]. The Schedule of Sub Vendors can be found at www.maryland.gov/SitePages/sf_gacct .aspx

6. The vendor agrees to comply with OMB Circular A-133, Audits of States, Local Governments and Non-Profit Organizations, which requires that certain recipients of federal funds have an independent “single audit” prepared.

Vendors are required to forward, within 30 days of issuance, all A-133 audits to the DHMH Audit Division to the following address:

Maryland Department of Health and Mental Hygiene Audit Division, RICA 605 S. Chapel Gate Lane (Old School Bldg.) Baltimore, MD 21229 7. The vendor affirms that services will be made available to those unable to pay for such services.

8. The vendor affirms that it has read and understands the Department of Health and Mental Hygiene (DHMH) regulation, COMAR 10.02.01, Charges for Services Provided through the Department of Health and Mental Hygiene, which requires that recipients of services and chargeable persons shall be liable for payment of services based on the ability to pay.

8.1 The vendor agrees to submit a Schedule of Charges as requested by the Division of Cost Accounting and Reimbursement, and to charge recipients of services the fee approved by the Department.

8.2 The vendor agrees to determine the recipient’s ability to pay the fee set by the Department as stipulated in COMAR 10.02.01.

8.3 The vendor agrees to use only the DHMH approved ability to pay schedules, unless another schedule has been approved by the Secretary.

8.4 The vendor agrees that failure to use the Department’s approved ability to pay schedule will result in an audit exception.

9. The vendor affirms that in relation to employment and personnel practices, there shall be no discrimination because of race, creed, color, sex or country of national origin.

9.1 The vendor agrees to comply with Title IX of the Education Amendments of 1972 (20 U.S.C. Sections 1681 et seq.) which prohibits sex discrimination in federally assisted education programs, including those in health care institutions.

9.2 The vendor agrees to comply with the Age Discrimination Act of 1975 (ADA) (426. S.C. Section 6101) which prohibits exclusion of any person on the basis of age from participating in any program or activity receiving federal financial assistance.

9.3 The vendor agrees to comply with the requirements of the Americans with Disabilities Act of 1990, where applicable, and will contact Program Administrator for specific compliance information.

9.4 The vendor agrees to submit an Affirmative Action Plan, (including, if applicable, a plan for Section 503 of the Rehabilitation Act.), to the Department of Health and Mental Hygiene Office of Community Relations within six (6) months after the date of the award letter if it has not already been submitted. If a current Affirmative Action Plan has been submitted give the date of submission.

10. The vendor agrees to comply with DHMH Policy 01.03.02 (Policy on Research Involving Human Subjects and the DHMH Institutional Review Board (IRB)) when conducting research involving human subjects.

11. The vendor agrees to complete and submit Certification Regarding Lobbying and Disclosure of Lobbying Activities. Public Law 101-121, Section 1352, prohibits any recipient of funds, which originated as federal funds, from using such funds to lobby Congress or any federal agency in connection with the award of a particular contract, grant, cooperative agreement or loan. A recipient of more than $100,000 of such funds must: (1) file a certification that they have neither used nor will use such funds for federal lobbying and, (2) disclose, on Standard Form LLL, the details of any agreements with lobbyists paid, with profits from federal contracts or with funds other than federal funds. Failure to file the required certification may be punishable by a civil penalty of not less than $10,000 and not more than $100,000 for each such failure. Prohibitions and Limitations on Lobbying by Grantees: Lobbying can be an attempt to influence legislation, or any government decision making, in the legislative or executive branches of government. It can be direct, or indirect, such as urging members of a special interest group or the public to support a member of a special interest group or the public to support a certain policy. OMB Circular A-122, Cost

Principles for Non-Profit Organizations specifies that most lobbying activities (to influence federal activities), as well as electioneering on the state or local level, are unallowable as charges to federal grants and contracts.

12. The vendor agrees to complete and submit the Certification Regarding Environmental Tobacco Smoke, P.L. 103-227, also known as the Pro-Children Act of 1994.

13. The vendor agrees to complete and submit the Certification Regarding Debarment, Suspension, and Other Responsibility Matters – Primary Covered Transactions and, where applicable, have its sub vendors complete Certification Regarding Debarment, Suspension, Ineligibility and Voluntary Exclusion – Lower Tier Covered Transactions.

14. The vendor agrees to complete and submit the Federal Fund Accountability and Transparency Act – Sub Recipient information form.

15. The current federal appropriation act law prohibits the use of federal funds from either the U.S. Department of Health and Human Services' National Institutes of Health (NIH)-which includes the National Cancer Institute) or the Substance Abuse and Mental Health Services Agency (SAMHSA), to pay the direct salary of an individual at a rate in excess of “Level 1 of the [federal] Executive Schedule.”

Date Submitted: ______Certified on Behalf of: ______

By: ______

Title: ______

Date: ______

Agreement Title: ______

Agreement Number: ______

Signature of Official: ______SCHEDULE OF SUB VENDORS FISCAL YEAR ______Page ______of ______

PRIMARY VENDOR:______COMPLETED BY:______CHIEF EXECUTIVE OFFICER'S SIGNATURE Date I certify, to the best of my knowledge, that the information submitted is true and correct. PHONE:______

E F If Column C is Yes and Column D is greater than $100,000 A B C D You must Complete Columns E & F G H I J K L DHMH Cost Reimb. Date of Period Count Award Contract - Amount of Last Covered CRF - Sub-Vendor's Name Address Federal Phone Number Purpose of Contract ** Number Yes or No * Contract Audit In Audit Yes or No I. D. Number 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25

* A cost reimbursement contract has a line item budget and requires a Form 440 to be submitted. ** Purpose of Contract - e.g., to provide family planning services; to provide tobacco cessation seminars

CERTIFICATION REGARDING LOBBYING

Certification for Contracts, Grants, Loans, and Cooperative Agreements

The undersigned certifies, to the best of his or her knowledge and belief, that:

(1) No Federal appropriated funds have been paid or will be paid, by or on behalf of the undersigned, to any person for influencing or attempting to influence an officer or employee of any agency, a Member of Congress, an officer or employee of Congress, or an employee of a Member of Congress in connection with the awarding of any Federal contract, the making of any Federal grant, the making of any Federal loan, the entering into of any cooperative agreement, and the extension, continuation, renewal, amendment, or modification of any Federal contract, grant, loan, or cooperative agreement.

(2) If any funds other than Federal appropriated funds have been paid or will be paid to any person for influencing or attempting to influence an officer or employee of any agency, a Member of Congress, an officer or employee of Congress, or an employee of a Member of Congress in connection with this Federal contract, grant, loan, or cooperative agreement, the undersigned shall complete and submit Standard Form-LLL, ``Disclosure Form to Report Lobbying,'' in accordance with its instructions.

(3) The undersigned shall require that the language of this certification be included in the award documents for all sub-awards at all tiers (including subcontracts, sub-grants, and contracts under grants, loans, and cooperative agreements) and that all sub-recipients shall certify and disclose accordingly.

This certification is a material representation of fact upon which reliance was placed when this transaction was made or entered into. Submission of this certification is a prerequisite for making or entering into this transaction imposed by section 1352, title 31, U.S. Code. Any person who fails to file the required certification shall be subject to a civil penalty of not less than $10,000 and not more than $100,000 for each such failure.

Award No. Organizational Entity

Name and Title of Official Signing for Organizational Entity Telephone No. Of Signing Official

Signature of Above Official Date Signed

Approved by OMB 0348-0046 DISCLOSURE OF LOBBYING ACTIVITIES

Complete this form to disclose lobbying activities pursuant to 31 U.S.C. 1352 (See page 2 for public burden disclosure.)

1. Type of Federal Action: 2. Status of Federal Action: 3. Report Type: a. contract a. bid/offer/application a. initial filing b. grant b. initial award b. material change c. cooperative agreement c. post-award For Material Change Only: d. loan year______quarter______e. loan guarantee date of last report______f. loan insurance 4. Name and Address of Reporting Entity: 5. If Reporting Entity in No. 4 is Subawardee, Enter Name Prime Subawardee and Address of Prime: Tier______, if known:

Congressional District, if known: Congressional District, if known:

6. Federal Department/Agency: 7. Federal Program Name/Description

CFDA Number, if applicable: ______

8. Federal Action Number, if known: 9. Award Amount, if known: $ ______

10.a.Name and Address of Lobbying Entity 10. b. Individuals Performing Services (including address if different from 10a) (if individual, last name, first name, MI): (last name, first name, MI):

(attach Continuation Sheet(s) if necessary) 11. Amount of Payment (check all that apply): 13. Type of Payment (check all that apply): $ ______actual planned a. retainer 12.Form of Payment (check all that apply): b. one-time fee c. commission a. cash d. contingent fee b. in-kind; specify: e. deferred nature ______f. other, specify: value ______

14.Brief Description of Services Performed or to be Performed and Date (s) of Services, including officer(s), employee(s), or Member(s) contacted, for Payment Indicated in Item 11:

(attach Continuation Sheet(s) SF-LLLA, if necessary)

15. Continuation Sheet(s) SF-LLLA attached: Yes No

16. Information required through this form is authorized by title Signature: ______31 U.S.C. section 1352. This disclosure of lobbying activities is a material representation of fact upon which reliance was placed by the tier above when this transaction was made or entered Print Name: ______into. This disclosure is required pursuant to 31 U.S.C. section 1352. This information will be reported to the Congress semiannually and will be available for public inspection. Any Title: ______person who fails to file the required disclosure shall be subject to a civil penalty of not less than $10,000 and not more than $100,000 for each such failure. Telephone No.:______Date:______Federal Use Only: Authorized for Local Reproduction Standard Form – LLL (Rev. 7-97)

1 INSTRUCTIONS FOR COMPLETION OF SF-LLL, DISCLOSURE OF LOBBYING ACTIVITIES

This disclosure form shall be completed by the reporting entity, whether subawardee or prime Federal recipient, at the initiation or receipt of a covered Federal action, or a material change to a previous filing, pursuant to title 31 U.S.C. section 1352. The filing of a form is required for each payment or agreement to make payment to any lobbying entity for influencing or attempting to influence an officer or employee of any agency, a Member of Congress, an officer or employee of Congress, or an employee of a Member of Congress in connection with a covered Federal action. Use the SF-LLL-A Continuation Sheet for additional information if the space on the form is inadequate. Complete all items that apply for both the initial filing and material change report. Refer to the implementing guidance published by the Office of Management and Budget for additional information.

1. Identify the type of covered Federal action for which lobbying activity is and/or has been secured to influence the outcome of a covered Federal action.

2. Identify the status of the covered Federal action.

3. Identify the appropriate classification of this report. If this is a follow-up report caused by a material change to the information previously reported, enter the year and quarter in which the change occurred. Enter the date of the last previously submitted report by this reporting entity for this covered Federal action.

4. Enter the full name, address, city, state and zip code of the reporting entity. Include Congressional District, if known. Check the appropriate classification of the reporting entity that designates if it is, or expects to be, a prime or subaward recipient. Identify the tier of the subawardee, e.g., the first subawardee of the prime is the 1st tier. Subawards include but are not limited to subcontracts, subgrants and contract awards under grants.

5. If the organization filing the report in item 4 checks “Subawardee”, then enter the full name, address, city, state and zip code of the prime Federal recipient. Include Congressional District, if known.

6. Enter the name of the Federal agency making the award or loan commitment. Include at least one organizational level below agency name, if known. For example, Department of Transportation, United States Coast Guard.

7. Enter the Federal program name or description for the covered Federal action (item 1). If know, enter the full Catalog of Federal Domestic Assistance (CFDA) number for grants, cooperative agreements, loans, and loan commitments.

8. Enter the most appropriate Federal identifying number available for the Federal action identified in item 1 (e.g., Request for Proposal (RFP) number; Invitation for Bid (IFB) number; grant announcement number; the contract, grant, or loan award number; the application/proposal control number assigned by the Federal agency). Include prefixes, e.g., "RFP-DE-90-001".

9. For a covered Federal action where there has been an award or loan commitment by the Federal agency, enter the Federal amount of the award/loan commitment for the prime entity identified in item 4 or 5.

10. (a) Enter the full name, address, city, state and zip code of the lobbying entity engaged by the reporting entity identified in item 4 to influence the covered Federal action.

(b) Enter the full names of the individual(s) performing services, and include full address if different from 10 (a). Enter Last Name, First Name, and Middle Initial (MI).

11. Enter the amount of compensation paid or reasonably expected to be paid by the reporting entity (item 4) to the lobbying entity (item 10). Indicate whether the payment has been made (actual) or will be made (planned). Check all boxes that apply. If this is a material change report, enter the cumulative amount of payment made or planned to be made.

12. Check the appropriate box (es). Check all boxes that apply. If payment is made through an in-kind contribution, specify the nature and value of the in-kind payment. 13. Check the appropriate box (es). Check all boxes that apply. If other, specify nature.

14. Provide a specific and detailed description of the services that the lobbyist has performed, or will be expected to perform, and the date(s) of any services rendered. Include all preparatory and related activity, not just time spent in actual contact with Federal officials. Identify the Federal official(s) or employee(s) contacted or the officer(s), employee(s), or Member(s) of Congress that were contacted.

15. Check whether or not a SF-LLL-A Continuation Sheet(s) is attached.

16. The certifying official shall sign and date the form; print his/her name, title, and telephone number.

Public reporting burden for this collection of information is estimated to average 30 minutes per response, including time for reviewing instruction, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the Office of Management and Budget, Paperwork Reduction Project (0348-0046), Washington, D.C. 20503.

2 CERTIFICATION REGARDING ENVIRONMENTAL TOBACCO SMOKE

Public Law 103-227, also known as the Pro Children Act of 1994, Part C Environmental Tobacco Smoke, requires that smoking not be permitted in any portion of any indoor facility owned, or leased or contracted for by an entity and used routinely or regularly for provision of health, day care, early childhood development services, education or library services to children under the age of 18, if the services are funded by Federal programs either directly or through State or local governments, by Federal grant, contract, loan, or loan guarantee. The law also applies to children’s services that are provided in indoor facilities that are constructed, operated or maintained with such Federal funds. The law does not apply to children's services provided in private residences, portions of facilities used for inpatient drug or alcohol treatment, service providers whose sole sources of applicable Federal funds is Medicare or Medicaid, or facilities where WIC coupons are redeemed. Failure to comply with the provisions of the law may result in the imposition of a civil monetary penalty of up to $1000 for each violation and/or the imposition of an administrative compliance order on the responsible entity.

By signing this certification, the offeror/contractor (for acquisitions) or applicant/grantee (for grants) certifies that the submitting organization will comply with the requirements of the Act and will not allow smoking within any portion of any indoor facility used for the provision of services for children as defined by the Act.

The submitting organization further agrees that it will require the language of this certification be included in any sub-awards which contain provisions for children's services and that all sub-recipients shall certify accordingly.

______Signature of Authorized Certifying Individual CERTIFICATION REGARDING DEBARMENT, SUSPENSION AND OTHER RESPONSIBILITY MATTERS

Certification Regarding Debarment, Suspension, and Other Responsibility Matters--Primary Covered Transactions

Instructions for Certification

1. By signing and submitting this proposal, the prospective primary participant is providing the certification set out below. 2. The inability of a person to provide the certification required below will not necessarily result in denial of participation in this covered transaction. The prospective participant shall submit an explanation of why it cannot provide the certification set out below. The certification or explanation will be considered in connection with the department or agency's determination whether to enter into this transaction. However, failure of the prospective primary participant to furnish a certification or an explanation shall disqualify such person from participation in this transaction. 3. The certification in this clause is a material representation of fact upon which reliance was placed when the department or agency determined to enter into this transaction. If it is later determined that the prospective primary participant knowingly rendered an erroneous certification, in addition to other remedies available to the Federal Government, the department or agency may terminate this transaction for cause or default. 4. The prospective primary participant shall provide immediate written notice to the department or agency to which this proposal is submitted if at any time the prospective primary participant learns that its certification was erroneous when submitted or has become erroneous by reason of changed circumstances. 5. The terms covered transaction, debarred, suspended, ineligible, lower tier covered transaction, participant, person, primary covered transaction, principal, proposal, and voluntarily excluded, as used in this clause, have the meanings set out in the Definitions and Coverage sections of the rules implementing Executive Order 12549. You may contact the department or agency to which this proposal is being submitted for assistance in obtaining a copy of those regulations. 6. The prospective primary participant agrees by submitting this proposal that, should the proposed covered transaction be entered into, it shall not knowingly enter into any lower tier covered transaction with a person who is proposed for debarment under 48 CFR part 9, subpart 9.4, debarred, suspended, declared ineligible, or voluntarily excluded from participation in this covered transaction, unless authorized by the department or agency entering into this transaction. 7. The prospective primary participant further agrees by submitting this proposal that it will include the clause titled ``Certification Regarding Debarment, Suspension, Ineligibility and Voluntary Exclusion-Lower Tier Covered Transaction,'' provided by the department or agency entering into this covered transaction, without modification, in all lower tier covered transactions and in all solicitations for lower tier covered transactions. 8. A participant in a covered transaction may rely upon a certification of a prospective participant in a lower tier covered transaction that it is not proposed for debarment under 48 CFR part 9, subpart 9.4, debarred, suspended, ineligible, or voluntarily excluded from the covered transaction, unless it knows that the certification is erroneous. A participant may decide the method and frequency by which it determines the eligibility of its principals. Each participant may, but is not required to, check the List of Parties Excluded from Federal Procurement and Nonprocurement Programs. 9. Nothing contained in the foregoing shall be construed to require establishment of a system of records in order to render in good faith the certification required by this clause. The knowledge and information of a participant is not required to exceed that which is normally possessed by a prudent person in the ordinary course of business dealings. 10. Except for transactions authorized under paragraph 6 of these instructions, if a participant in a covered transaction knowingly enters into a lower tier covered transaction with a person who is proposed for debarment under 48 CFR part 9, subpart 9.4, suspended, debarred, ineligible, or voluntarily excluded from participation in this transaction, in addition to other remedies available to the Federal Government, the department or agency may terminate this transaction for cause or default. Certification Regarding Debarment, Suspension, and Other Responsibility Matters--Primary Covered Transactions

(1) The prospective primary participant certifies to the best of its knowledge and belief, that it and its principals: (a) Are not presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded by any Federal department or agency; (b) Have not within a three-year period preceding this proposal been convicted of or had a civil judgment rendered against them for commission of fraud or a criminal offense in connection with obtaining, attempting to obtain, or performing a public (Federal, State or local) transaction or contract under a public transaction; violation of Federal or State antitrust statutes or commission of embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements, or receiving stolen property; (c) Are not presently indicted for or otherwise criminally or civilly charged by a governmental entity (Federal, State or local) with commission of any of the offenses enumerated in paragraph (1)(b) of this certification; and (d) Have not within a three-year period preceding this application/proposal had one or more public transactions (Federal, State or local) terminated for cause or default. (2) Where the prospective primary participant is unable to certify to any of the statements in this certification, such prospective participant shall attach an explanation to this proposal.

As the duly authorized representative of the applicant, I hereby certify that the applicant will comply with the above certifications.

NAME OF APPLICANT

AWARD NUMBER AND / OR PROJECT NAME

PRINTED NAME AND TITLE OF AUTHORIZED REPRESENTATIVE

SIGNATURE DATE Certification Regarding Debarment, Suspension, Ineligibility and Voluntary Exclusion--Lower Tier Covered Transactions

Instructions for Certification

1. By signing and submitting this proposal, the prospective lower tier participant is providing the certification set out below. 2. The certification in this clause is a material representation of fact upon which reliance was placed when this transaction was entered into. If it is later determined that the prospective lower tier participant knowingly rendered an erroneous certification, in addition to other remedies available to the Federal Government the department or agency with which this transaction originated may pursue available remedies, including suspension and/or debarment. 3. The prospective lower tier participant shall provide immediate written notice to the person to which this proposal is submitted if at any time the prospective lower tier participant learns that its certification was erroneous when submitted or had become erroneous by reason of changed circumstances. 4. The terms covered transaction, debarred, suspended, ineligible, lower tier covered transaction, participant, person, primary covered transaction, principal, proposal, and voluntarily excluded, as used in this clause, have the meaning set out in the Definitions and Coverage sections of rules implementing Executive Order 12549. You may contact the person to which this proposal is submitted for assistance in obtaining a copy of those regulations. 5. The prospective lower tier participant agrees by submitting this proposal that, [[Page 33043]] should the proposed covered transaction be entered into, it shall not knowingly enter into any lower tier covered transaction with a person who is proposed for debarment under 48 CFR part 9, subpart 9.4, debarred, suspended, declared ineligible, or voluntarily excluded from participation in this covered transaction, unless authorized by the department or agency with which this transaction originated. 6. The prospective lower tier participant further agrees by submitting this proposal that it will include this clause titled ``Certification Regarding Debarment, Suspension, Ineligibility and Voluntary Exclusion-Lower Tier Covered Transaction,'' without modification, in all lower tier covered transactions and in all solicitations for lower tier covered transactions. 7. A participant in a covered transaction may rely upon a certification of a prospective participant in a lower tier covered transaction that it is not proposed for debarment under 48 CFR part 9, subpart 9.4, debarred, suspended, ineligible, or voluntarily excluded from covered transactions, unless it knows that the certification is erroneous. A participant may decide the method and frequency by which it determines the eligibility of its principals. Each participant may, but is not required to, check the List of Parties Excluded from Federal Procurement and Nonprocurement Programs. 8. Nothing contained in the foregoing shall be construed to require establishment of a system of records in order to render in good faith the certification required by this clause. The knowledge and information of a participant is not required to exceed that which is normally possessed by a prudent person in the ordinary course of business dealings. 9. Except for transactions authorized under paragraph 5 of these instructions, if a participant in a covered transaction knowingly enters into a lower tier covered transaction with a person who is proposed for debarment under 48 CFR part 9, subpart 9.4, suspended, debarred, ineligible, or voluntarily excluded from participation in this transaction, in addition to other remedies available to the Federal Government, the department or agency with which this transaction originated may pursue available remedies, including suspension and/or debarment. Certification Regarding Debarment, Suspension, Ineligibility an Voluntary Exclusion--Lower Tier Covered Transactions

(1) The prospective lower tier participant certifies, by submission of this proposal, that neither it nor its principals is presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from participation in this transaction by any Federal department or agency. (2) Where the prospective lower tier participant is unable to certify to any of the statements in this certification, such prospective participant shall attach an explanation to this proposal.

As the duly authorized representative of the applicant, I hereby certify that the applicant will comply with the above certifications.

NAME OF APPLICANT

AWARD NUMBER AND / OR PROJECT NAME

PRINTED NAME AND TITLE OF AUTHORIZED REPRESENTATIVE

SIGNATURE DATE Federal Funding Accountability and Transparency Act

Sub-Recipient Information

Sub-recipient's DUNS Number (provide 4 digit suffix if applicable) VENDOR NAME AND ADDRESS (Same information associated with the DUNS NUMBER provided above) Name: Address 1: Address 2: City: State: Zip + 4: Country:

VENDOR NAME AND ADDRESS (Primary Place of Performance - Complete if Different from Above) City: State: Zip + 4: Country: Sub-recipient's Federal Tax Identification Number

In your business or organization's preceding completed fiscal year, did your business or organization (the legal entity represented by the above DUNS number) receive (1) 80 percent or more of your annual gross revenues in U.S. federal contracts, subcontracts, loans, grants, subgrants, and/or cooperative agreements; and (2) $25,000,000 or more in annual gross revenues from U.S. federal contracts, subcontracts, loans, grants, subgrants, and/or cooperative agreements? □ YES □ NO If answer is YES, answer next question below. Does the public have access to information about the compensation of the executives in your business or organization (the legal entity represented by the above DUNS number) through periodic reports filed under section 13(a) or 15(d) of the Securities Exchange Act of 1934 (15 U.S.C. §§ 78m(a), 78o(d)) or section 6104 of the Internal Revenue Code of 1986? □ YES □ NO If answer is NO, provide your entity's Top 5 Highly Compensated Officers below. List Top 5 Highly Officer's Name Officer's Compensated Officers Compensation

Optional - Provide additional comments below to explain your answers.